Valor predictivo de la hipoalbuminemia pre-tratamiento sobre el pronóstico del cáncer colorrectal resecado

Introduction

Albuminemia is part of the antitumoral systemic inflammatory response. We therefore analyzed its possible value in establishing the preoperative prognosis of colorectal carcinoma (CRC).

Patients and methods

We conducted a retrospective, observational study of a series of consecutive patients who underwent CRC resection. Univariate and multivariate analyses of survival curves were performed in patients with and without pre-treatment hypoalbuminemia (< 3.5 g/dl), both in the overall group of patients and in the subgroup of those with pTNM stage ii tumors. In addition, we compared the 5-year tumor-related mortality in patients with and without hypoalbuminemia.

Results

A total of 207 patients were reviewed (median follow-up: 81 months). In the overall multivariate analysis, survival curves were better in patients with normal albumin levels than in those with hypoalbuminemia (HR = 2.82; CI 95% = [1.54-5.19]; P = .001). This better prognostic value of normal albumin levels was also significant in pTNM stage ii tumors: (HR = 3.76; CI 95% = [1.40-10.08]; P = .009). The 5-year mortality index was lower in patients with normal albumin levels: overall series = 18.8% vs 42.9% (OR = 3.24; CI 95% = [1.48-7.12]; p = 0.001); pTNM stage ii = 13.3% vs 44.4% (OR = 5.2; CI 95% = [1.36-20.34]; P = 0.004).

Conclusions

Pre-treatment hypoalbuminemia (< 3.5 g/dl) was independently related to shorter survival after tumor resection, both in the overall series of patients and in pTNM stage ii CRC. If these results are confirmed, hypoalbuminemia would be a simple and significant marker of poor prognosis, available at the initial diagnosis.     

Metástasis exclusivas en el timo de un cáncer de pulmón no microcítico resecado

Primary thymic tumors are rare, but secondary ones are exceptionally uncommon. We report the case of a single metastasis within the thymic gland from a lung adenocarcinoma that had been completely resected 3 years before. There was high diagnostic doubt because the thymic lesion was not associated with the recurrence of the paraneoplastic syndrome or the increased CEA levels described at the moment of the treatment of the primary tumor. The lesion was diagnosed and treated at the same time by transcervical thymectomy. At the one-year follow-up, the patient is alive and disease-free.     

Valor pronóstico de la oclusión total crónica de una arteria no responsable en el infarto agudo de miocardio tratado con angioplastia primaria

Introduction and objectives

The prognostic value of chronic total occlusion in nonculprit coronary arteries in patients with myocardial infarction undergoing primary angioplasty remains controversial. Several publications have described different methodologies and conflicting findings. In addition, causes of death were not reported. Our aim is to analyze the prognostic impact of chronic total occlusion in nonculprit coronary arteries and the role of left ventricular ejection fraction in this analysis.

Methods

Prospective inclusion of consecutive patients with ST-segment elevation myocardial infarction who underwent primary angioplasty. We recorded baseline characteristics, in-hospital clinical course, and mortality and its causes during follow-up. We assessed the impact of chronic total occlusion on mortality using Cox regression analysis.

Results

Chronic total occlusion in nonculprit arteries was present in 125 of 1176 patients (10.6%); in 79 of these 125 patients, chronic total occlusion was present in the proximal segments. The mean follow-up was 339 days; 64 (5.8%) patients died during the first 6 months. Patients with chronic total occlusions had more comorbidities, poorer ventricular function, and higher mortality (hazard ratio=2.79; 95% confidence interval, 1.71-4.56). Chronic total occlusion was also associated with noncardiac death (hazard ratio=3.83; 95% confidence interval, 2.10-7.01). Chronic total occlusion in proximal segments was associated with both cardiac (hazard ratio=3.22; 95% confidence interval, 1.42-7.30) and noncardiac deaths (hazard ratio=3.43; 95% confidence interval, 1.67-7.06). The multivariate analysis performed without including left ventricular ejection fraction showed a significant association between chronic total occlusion and mortality. However, when left ventricular ejection fraction was included in the analysis, this association was nonsignificant (hazard ratio=1.76; 95% confidence interval, 0.85-3.65; P=.166).

Conclusions

Chronic total occlusion in this clinical setting identified patients at higher risk with more comorbidities and higher mortality, but did not behave as an independent predictor of mortality when left ventricular ejection fraction was included in the analysis.Full English text available from:www.revespcardiol.org/en     

Utilidad de la PAAF guiada por TC en el diagnóstico de lesiones mediastínicas

Objective

To evaluate the diagnostic accuracy of the percutaneous fine needle aspiration cytology (FNAC) for mediastinal lesions by using histology or follow-up clinical diagnosis as gold standard.

Patients and Methods

CT-guided percutaneous FNAC was performed on 131 patients with mediastinal lesions. Helical CT was used with 3–10 mm image thickness range and low radiation dose (40 mAs, 120 kV). Samples were immediately examined by a cytologist to determine if they were representative. Histological samples were obtained by means of biopsy or resection specimens in 73 patients and clinical follow-up in 50.

Results

The material was satisfactory for diagnosis in 126 patients (95.2 %), in whom 103 lesions (78.6%) were considered malignant (62 primary tumours and 41 metastases) and 23 (17.6%) benign. In the 123 patients with clinical monitoring or pathological diagnosis, using FNAC led to the identification of malignancy with a sensitivity of 95.2 % (95%CI: 89.2–97.9%), specificity 84.2% (95%CI: 62.4–94.5%), positive predictive value 97.1% (95%-CI: 91.7–99.0%), negative predictive value 76.2% (95%CI: 54.9–89.4%), likelihood-ratio positive 6.03 (95%CI: 2.13–17.05) and accuracy 93.5% (95%CI: 87.7–96.7%). Pneumothorax was the most frequent complication (3 cases). There was good agreement between the cytological findings and the histological findings, not only for malignant lesions (kappa coefficient: 0.641) but also for benign (kappa 0.607).

Conclusions

CT-guided percutaneous FNAC is a safe and effective technique for the diagnosis of the mediastinal masses, with a high diagnostic yield for malignancy depicting.     

Impacto del 18F-FDG PET/TC en el abordaje terapéutico del cáncer de pulmón no microcítico

Introduction

Disease stage is the most important prognostic factor in lung cancer, and optimal staging is important to determine the best therapeutic option. FDG-PET/CT has demonstrated its value in early stage non-small cell lung cancer (NSCLC) but there is still insufficient data to define its role in other stages.

Hypothesis

Information provided by FDG-PET/CT has an impact on the therapeutic management of patients with NSCLC.

Methods

A retrospective review was made of patients who underwent FDG-PET/CT between January 2008 and December 2010 for the diagnosis of NSCLC. Clinical stage before and after FDG-PET/CT and information about any change in therapeutic decision due to information provided by FDG-PET/CT were collected. Using pathologic evaluation as the gold standard, sensitivity, specificity, and positive and negative predictive values for CT and FDG-PET/CT were calculated.

Results

Of the 522 patients diagnosed of NSCLC, FDG-PET/CT was performed in 246 (47.1%). In 85 cases (34.6%) FDG-PET/CT led to stage migration. Treatment was modified in 60 patients (24.4% of all FDG-PET/CT performed), avoiding a futile thoracotomy in 13 cases (5.2%), and allowing treatment with curative intent in 26 (10.5%). Out of 90 patients (36.5%) evaluated as stage iii by CT staging, FDG-PET/CT modified the therapeutic approach in 36 (40%). For the 133 cases (54%) with pathological assessment of the mediastinal lymph nodes, sensitivity, specificity, positive predictive value and negative predictive value were 0.57, 0.64, 0.48 and 0.72 for CT, and 0.68, 0.86, 0.75 and 0.81 for FDG-PET/CT.

Discussion

Our data support previous reports that FDG-PET/CT is essential in the staging process not only for patients with potentially operable NSCLC but also for stage iii patients, as demonstrated by our data.     

Avances en el diagnóstico molecular de la enfermedad de Wilson

Wilsońs disease is an autosomal recessive disorder characterized by toxic copper accumulation in the liver and subsequently in the brain and other organs. Clinical diagnosis is based on the detection of low serum ceruloplasmin concentrations, increased urinary copper excretion, Kayser-Fleisher rings in the cornea, and/or high copper levels in hepatic tissue. Diagnosis can be difficult when the typical symptoms of the disease are absent, a situation that can lead to a lack of prophylactic therapy in these patients. Molecular study has improved the diagnosis of this disease, even in doubtful cases. The present article outlines the various techniques applied in the molecular diagnosis of Wilson's disease and the most commonly described mutations. Currently, direct sequencing of the ATP7B gene is the most widely used method to detect mutations. Molecular study and identification of ATP7B gene mutations allow diagnosis of individuals with Wilson's disease and their relatives, as well as the possibility of genetic counselling and prenatal and preimplantation genetic diagnosis.     

Validación de 2 escalas clínicas pronósticas en pacientes con tromboembolia pulmonar aguda sintomática

Objective

The aim of this study was to compare the predictive value of two clinical prognostic models, the Spanish score and the simplified Pulmonary Embolism Severity Index (sPESI), in an independent cohort of patients diagnosed of acute symptomatic pulmonary embolism (PE).

Methods

We performed a retrospective analysis of a cohort composed of 1447 patients with acute symptomatic PE. The Spanish score and the sPESI were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for 30-day mortality, and a composite of non fatal recurrent venous thromboembolism and non fatal major bleeding, using C statistic, which was obtained by means of logistic regression and ROC curves.

Results

Overall, 138 patients died (9.5%) during the first month of follow-up. Both scores showed an excellent predictive value for 30-day all-cause mortality (C statistic, 0.72 and 0.74), but the performance was poor for the secondary endpoint (C statistic, 0.60 and 0.59). The sPESI classified fewer patients as low risk (32% versus 62%; P < .001). Low-risk patients based on the sPESI had a lower 30-day mortality than those based on the Spanish score (1.1% versus 4.2%), while the 30-day rate of non fatal recurrent VTE or major bleeding was similar (2.2% versus 2.3%).

Conclusions

Both scores provide excellent information to stratify the risk of mortality in patients treated of PE. The usefulness of these models for nonfatal adverse events is questionable. The sPESI identified low-risk patients with PE better than the Spanish score.     

Viabilidad de las muestras ganglionares obtenidas por ecobroncoscopia para el estudio de alteraciones epigenéticas en pacientes con cáncer de pulmón

Introduction

The diagnosis of microscopic lymph node metastasis in lung cancer is challenging despite the constant advances in tumor staging. The analysis of the methylation status of certain genes in lymph node samples could improve the diagnostic capability of conventional cyto-histological methods. The aim of this study was to demonstrate the feasibility of methylation studies using cytological lymph node samples.

Methods

Prospective study including 88 patients with a diagnosis or strong suspicion of non-small cell lung cancer, in which an echobronchoscopy was performed on mediastinal or hilar lymph nodes for diagnostic and/or staging. DNA was extracted from cytological lymph node samples and sodium bisulfite modification was performed. Methylation studies for p16/INK4a and SHOX2 were accomplished by MS-qPCR and pyrosequencing.

Results

The methodology used in our study yielded optimal/good DNA quality in 90% of the cases. No differences in DNA concentration were observed with respect to the lymph node biopsied and final diagnosis. Methylation analyses using MS-qPCR and pyrosequencing were not possible in a small number of samples mainly due to low DNA concentration, inadequate purity, fragmentation and/or degradation as a consequence of bisulfite conversion.

Conclusion

Methylation quantification using MS-qPCR and pyrosequencing of cytological lymph node samples obtained using echobronchoscopy is feasible if an appropriate DNA concentration is obtained, notably contributing to the identification of epigenetic biomarkers capable of improving decision-making for the benefit of potentially curable lung cancer patients.     

Desarrollo de indicadores para evaluar los programas de prevención del cáncer colorrectal en la población de riesgo alto. La experiencia de la Clínica de Alto Riesgo

Background/objective

In 2006, the High-Risk Colorectal Cancer (CRC) Clinic was set up in Barcelona, a new healthcare model aimed at individuals and/or patients with an increased risk of developing CRC. The aim of this study was to develop a set of indicators to evaluate CRC prevention programs in the high-risk population and to implement them in the CRC to confirm their feasibility and validity in identifying areas for improvement.

Methods

A literature search was performed and consensus techniques were applied with experts linked to the prevention programs in the distinct autonomous regions in Spain to propose a conceptual model for the evaluation and indicators. Users’ opinions were introduced through focus groups for the proposed set of indicators. All experts participating in the consensus meetings and Delphi study evaluated the importance of each indicator (from 1 to 10) and their degree of agreement (agree strongly, agree with modifications, or eliminate this indicator). Expert consensus was considered to have been reached when 80% strongly agreed or agreed with the inclusion of the indicator. In the implementation phase, we included users (with advanced colorectal adenocarcinoma, polyposis syndrome, CRC or a familial history of CRC) attending the program. Information was obtained from computerized medical histories and clinical documentation. In addition, health professionals linked to the program were surveyed. To calculate each indicator, its formula was computed and the indicator was then compared with a standard previously agreed on by the experts in the first phase.

Results

Expert consensus was reached in 30 indicators. In the implementation phase, 21 feasible indicators that showed the greatest simplicity and validity in identifying areas for improvement were calculated. Of these, two measured aspects related to accessibility, seven measured patient-centered care, five measured continuity of care, one measured patient safety and four evaluated clinical effectiveness. Overall, eight of the 17 indicators achieved the previously agreed standard of quality of care.

Conclusions

The robustness and importance of the proposed set of indicators is supported by the wide participation of experts from distinct specialties and the adequate agreement reached. The present study serves to identify areas for improvement in the program. Periodic measurement of these indicators will allow the changes produced in this program and their utility to be evaluated and will aid assessment of other CRC prevention programs in the high-risk population.     

Evaluación económica de la elastografía de transición (FibroScan) en el diagnóstico de fibrosis hepática en pacientes con hepatitis C coinfectados con VIH

Introduction

The assessment of liver fibrosis is crucial for taking therapeutic decisions in patients infected with HIV/AIDS coinfected with HCV, because it allows the prognosis of the disease and the prioritization of hepatitis C treatment in these patients.

Methods

A discrete events model simulation (DEMS) and a Markov model have been developed to represent the evolution of liver fibrosis to cirrhosis in patients coinfected with HIV/HVC. The model evaluated two alternatives for the diagnosis and monitoring of these patients, transient elastography performed annually and liver biopsy performed every seven years. The models have been developed under Health Care System perspective and only considered direct medical costs (disease treatment and health state costs). One-way sensitivity analyses were carried out to assess the impact of parameters with higher uncertainty. A discount rate of 3% was applied.

Results

Base case analysis shows that the diagnosis and monitoring of patients with transient elastography is a dominant strategy compared with to liver biopsy, resulting in greater life expectancy at lower cost. The sensitivity analysis performed confirmed the robustness of these results.

Conclusion

Transient elastography has proved to be a dominant strategy compared to liver biopsy in the diagnosis and monitoring of liver fibrosis in patients coinfected with HIV/HCV in Spain.     

Imaginando el futuro del diagnóstico por imagen

Cardiovascular imaging has become essential to achieving a better understanding of cardiovascular diseases. Due to the advent of new technology and the refinement of existing technologies, imaging's role has extended into the biological, functional, and hemodynamic diagnosis of multiple pathophysiologic processes. Current and future trends in cardiovascular imaging will focus on improving early diagnosis of vascular disease, so as to be able to promote cardiovascular health, and on its development as a useful tool in clinical decision-making. Imaging is also increasingly used to quantify the effect of novel therapies. The rapid development of molecular imaging and fusion imaging techniques improves our understanding of cardiovascular processes from the molecular and cellular points of view and makes it possible to design and test new preventive interventions. The proliferation and integration of imaging techniques in different clinical areas and their role in “translational imaging” plays an important part in the implementation of personalized therapeutic and preventive management strategies for patients with cardiovascular disease.     

Endocarditis infecciosa en 2 hospitales universitarios españoles que difieren en su localización y en la presencia de servicio quirúrgico

Objectives

To assess possible differences in clinical presentation, microbiology, morbidity and mortality of infective endocarditis between two Spanish hospitals, one on the mainland that has cardiac surgery and one in the Canary Islands without this service.

Method

A total of 229 patients consecutively diagnosed of endocarditis between 2005 and 2012, including pediatric population, were studied in the Reina Sofía Hospital (Córdoba, n = 119) and Nuestra Señora de Candelaria Hospital (Tenerife, n = 110). We compared the clinical, microbiological and echocardiographic data and analyzed mortality differences by binary logistic regression analysis.

Results

There were no differences in underlying heart disease, proportion of surgery, or the microbiological profile. The proportion of infections attributable to catheter was higher in the Canary Islands hospital (13.6% vs 3.4%). Mortality was also higher (31.8% vs 18.5%, P = .020), although this difference was no longer significant in the multivariate analysis (OR = 1.85; 95% CI, 0.70-4.87; P = .213). Age (OR = 1.04/year; 95% CI, 1.01-1.07; P = .006), cardiac complications (OR = 5.05; 95% CI, 1.78-14.34; P = .002), persistent sepsis (OR = 4.89; 95% CI, 2.09-11.46; P < .001), and emergent surgery (OR = 4.43, 95% CI, 1.75-11.19; P = .002) were independent predictors of death. Time to surgery, length of stay in the hospital without a surgical service (20 [13-30.5] vs 13 [6-25] days; P = .019) was not associated with outcome.

Conclusions

There are differences in the presentation of endocarditis between two distant hospitals in Spain. The different hospital mortality can not be directly related to the presence of a surgery service.